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Appendix V1 <br /> Underground Storage Tank <br /> Monitoring y temertifi arition Form <br /> TYPE OF ACTION ® Installation Ifl Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10919469 0113112025 <br /> Facility flame <br /> Grappa Market <br /> TO, 1ty Ad'dress City ZIP Code <br /> 704 N. Jack Tone Ind. Ripon[2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors (209)-461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. 95205 <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> Contractor/Tank Tester License Number <br /> 1001331-A <br /> ICC plumber xpirat ion Date <br /> 9519380 06/0412026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training CerfificaUons Expiration Date <br /> Veeder-Root Tech 027440 1211412026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitorings systema is operational in accordance with California Cade <br /> of Regulations, title Tar division 3, chapter 16, section 2838; that required supporting <br /> documentation is attached; and all infornnafion contained herein is accurate. <br /> Service Technician Signature Date Total # of Mages <br /> 0113112025 2 <br /> FRS = California Environmental Reporting System, G P H = Gallons Per Hour. ID = Idenffication, <br /> ICC = international Code Council, LLD = Line teak Detector, NA = Not Applicable, SW= Sing[e- <br /> Walled, UDC = Under-Dispenser C ontainment, UST = Underground Storage Tank, <br /> VPH = VacuumlPressure{Hydrostatic <br /> Page 1 of 6 <br />